Nokea
A 30 month-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse to select from the toy room for this child?
- A. Cartoon stickers
- B. Large wooden puzzle
- C. Blunt scissors and paper
- D. Beach ball
Correct Answer: B
Rationale: Large wooden puzzle. This is age-appropriate, supporting fine motor skills and cognitive development.
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Which of the following actions should the nurse instruct the client to complete FIRST to establish a normal urinary pattern?
- A. Urinate every two hours.
- B. Record each time you urinate.
- C. Keep a record of your daily fluid intake.
- D. Stay near a bathroom.
Correct Answer: C
Rationale: Tracking fluid intake first helps correlate intake with urinary output, guiding interventions like scheduled voiding. Options A, B, and D are subsequent steps or supportive measures.
The nurse is caring for a client who is 2 days postoperative after a cholecystectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 99.5°F (37.5°C).
- B. Pain at the incision site.
- C. Yellowish drainage from the incision.
- D. Urine output of 1500 mL in 24 hours.
Correct Answer: C
Rationale: Yellowish drainage from the incision suggests infection or bile leakage, a serious complication post-cholecystectomy requiring immediate evaluation. Options A, B, and D are expected or normal: slight fever is common, incision pain is typical, and urine output is adequate.
A client in the intensive care unit is overheard telling his wife, 'It's impossible to get any sleep in this place with all the noise and lights on all the time.' After talking with the client, the nurse determines that the client is bothered by sensory disturbance related to being in the ICU. Which laboratory finding would confirm the nurse's assessment of sensory disturbance?
- A. Increased urine catecholamines
- B. Decreased TSH
- C. Erratic changes in BUN levels
- D. Increased blood glucose levels
Correct Answer: A
Rationale: Sensory disturbance and stress in the ICU increase catecholamines (e.g., epinephrine), detectable in urine. Other labs are unrelated to sensory disturbance.
Before administering calcium gluconate 10% 500 mg IV stat.
It is MOST important that the nurse assess the
- A. stability of the respiratory system.
- B. adequacy of urine output.
- C. patency of the vein.
- D. availability of magnesium sulfate injection.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to calcium gluconate. (1) unnecessary in this situation (2) unnecessary in this situation (3) correct-if injected into the extravascular tissues, calcium gluconate can cause a severe chemical burn (4) irrelevant
A client has been diagnosed with metastatic cancer with a poor prognosis. Recently, the client has complained of increased pain and is less communicative, very irritable, and anorexic.
Which of the following nursing goals should be a priority at this time?
- A. Encourage client to talk about the possibility of dying.
- B. Provide pain assessment and effective pain management.
- C. Manage nutrition and hydration.
- D. Verify that the physician has discussed the prognosis with the family.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will be difficult if client's pain is not adequately controlled (2) correct-comprehensive and regular pain assessment/management is necessary to facilitate client's ability to maintain comfort, which may enable him to verbalize his feelings (3) important, but will be difficult if client's pain is not adequately controlled (4) not highest priority